Ask Dr. Z

Would this scenario be coded as 92941 or 92920 since the MI occurred during a non-emergent LHC? 

"Emergent PCI indicated for distally embolized atheroembolic material in LM occluding LC after diagnostic LHC. PTCA with 2.5 mm x 12 mm in mL CX restoring TIMI II flow in OM2. TIMI 0 flow remained in OM3. Minamo wire was unable to transverse thrombus in OM3. A Sion black wire was placed in OM3 branch, which transversed the thrombus and was dilated. IVUS in mid OM3 showed embolized atheroma with thrombus. Pronto LP placed in OM3 for aspiration, which did not improve TIMI flow. Dilations completed with 2 x 10 compliant balloon restoring TIMI I flow distal OM1. Dilation in OM2 completed d/t thrombotic debris. OM2 appeared normal with TIMI III flow. Pronto LP placed distally in OM3 and distal vasculature bathed in 600mg of IC Cardene followed by aspiration thrombectomy. This restored TIMI III flow in the vessel; however, residual thrombus was identified."

Can you advise if there is a CPT code to report for this procedure or if this would be reported with an E/M code? This is for hospital billing for an outpatient in the interventional radiology suite. There was only an aspiration of pleural fluid from the existing drainage catheter and no imaging or further intervention.

"INDICATION: Previously placed right-sided pleural drainage catheter for malignant pleural effusion. Decreased amount of drainage.

At the time of presentation 300 cc of fluid were aspirated from the existing pleural drainage catheter. Therefore, it was decided that the Pleurx catheter would not be removed."

How would you code for quantity 10, FNA CT guided hepatic cysts aspirations (no labs ordered)? 10160 x10 and 77012 or 10009 and 10010 x 9?

"Left femoral artery was surveyed via ultrasound. A 22-gauge needle was used to access the apex of the left com fem artery over the femoral head. An .018 wire was then advanced into the ext iliac artery and confirmed with fluoroscopy. The 22-gauge needle was exchanged for a 4 french x 10 cm pinnacle sheath. A soft angle glide wire was then advanced into the infrarenal aorta and a 4 French Kumpe catheter was tracked over it. The infrarenal aorta, com iliac arteries, and the takeoff of the iliorenal bypass were imaged via DSA (all widely patent). We attempted to use the 4 French Kumpe catheter and a soft angle glide wire to access the iliorenal bypass but were unsuccessful. We exchanged the Kumpe catheter for an omni flush catheter which allowed us to gain access to the iliorenal bypass with the soft angle glide wire. A diagnostic angiogram was performed which revealed that the iliorenal bypass was widely patent, as was the anastomosis between the graft and the left renal artery."

Not sure on cath placement and S&I for this. Would this be 36245, 75625?

It is recommended by ACR that whole-body MRI be reported with unlisted code 76498. Our institution provides whole-body MRI where different body structures are read by different radiologists. Do you still recommend using an unlisted code for one provider or coding each study separately to the reading radiologist? Example: there are different radiologist reads for each of the following studies: neck, chest, abdomen, and pelvis. Would we report these with individual CPT codes or with the unlisted code?

What is the correct CPT code for superior hypogastric nerve block?

1.  Highly vascular nasopharyngeal tumor, consistent with JNA, supplied by the bilateral internal carotid arteries, middle meningeal arteries, multiple branches of the bilateral internal maxillary arteries, and the right ascending pharyngeal artery.

 2.  Extensive embolization was performed via the bilateral vidian arteries (ICA branches), right middle meningeal artery, right proximal internal maxillary artery, right ascending pharyngeal artery, left distal internal maxillary artery, and left accessory meningeal artery.

Questioning 61624 or 61626, or both? Thanks!

RIA was cannulated a interlock detachable coil was advanced into RIA however, were unable to advance the full deployment mechanism around the curve of the cath attempted repositioning was, the coil itself began to unwind. Multiple wires were utilized to attempt advancement of the coil mechanism this was unsuccessful as the coils integrity had failed. To preserve access, a buddy wire was placed. The coil was removed with confirmation. No further attempts at coil embolization were made. Over a wire system Perclose technique was then performed to the RCFA access and following serial dilation that became difficult due to the degree of scar the sheath was eventually upsized to a 12 French which was advanced to the level of the endograft limb. A Gore excluder iliac limb was then deployed just distal to the flow divider followed by deployment of covered balloon expandable VBX stent spanning the distal aspect of the newly deployed endograft limb and into the native proximal external iliac artery with post dilation. 34718 vs 34710 with attempt coils?

How would the following surgery be reported?

Operation Performed: Excision of retained CAPD cuff, debridement of granulation tissue

Procedure Details: The operative field was then prepped and draped in a sterile manner. After infiltration with local anesthesia a small transverse incision was made directly over the palpable cuff. Dissection was carried down till the cuff was encountered and could be excised using a combination of blunt dissection and cautery. With the cuff out, the residual cavity was apparent and noted to be lined with granulation tissue. Gauze was passed through the cavity and out the old exit site and used to debride all the granulation tissue away until only subcutaneous fat was visible. The wound was then inspected for hemostasis and closed with 3-0 vicryl for deep subcutaneous tissue and subcuticular 4-0 vicryl for skin. Dermabond was applied. The exit site was packed with antibiotic ointment and gauze and covered with a sterile dressing. This completed the procedure.

Patient was brought to the lab for dual chamber ICD replacement due to battery depletion. The pocket was opened and the generator removed. The RV and RA leads disconnected. Leads are then connected to the new dual chamber ICD, but the new device malfunctioned. The leads were disconnected from the new device. The RA lead was capped and the RV lead was connected to a new single chamber ICD. Should we code for the final completed procedure 33262 or the attempted procedure 33263-74?

In a previous 2019 response it was stated that 37215 and 37216 were reportable with 61645 if separate carotid stent was placed. Is this still true today? We had a case in which the patient had a complete occlusion of the right ICA, and this appeared to be at the skull base. The stent was deployed at the occluded segment of the petrous cavernous ICA. Is this an area which can be considered a carotid stent placement?

How should the following be coded? We believe this would be coded as a trigger point injection per CPT Assistant (October 2021); however, would this be considered two or four muscle Botox injections? We are having a hard time understanding which “muscles” are injected, as it seems to be the “fascia” technically being injected, which will target the muscles.

"A total of 1 mL of 100 units of botulinum toxin (1 mL of saline added to 100 units), 4 mL of 50 mg Kenalog (total 40 mg injected), and approximately 6 mL of 0.25% Marcaine were then mixed. The injections were then carried out under direct finger guidance into the obturator and levator fascia bilaterally, going from approximately the 1 o'clock to the 5 o'clock position in the mid vagina, and then the 7 to 11 o'clock position also in the mid vagina at this time on the right. After this was done, the fluid was then gently massaged into the tissues."

I have a physician who wants me to bill for additional cath placement during fistulogram with angioplasty.

Physician documents first cannulation site near the distal end and pointed in an antegrade direction. Second cannulation of proximal end of fistula pointed in retrograde direction. (He thinks this second cannulation site is billable.)

After researching I feel this is included in the work done for 36902, since it was in the peripheral segment?

Our surgeon is placing a left atrial appendage occlusion device (Watchman).

"Further left appendage angiogram performed in orthogonal views to determine the anatomy. The device then deployed. Device size, compression, seal, and stability are assessed with angiogram as well as TEE."

We do not see any NCCI edits between these two CPT codes; however, the thought is that this is checking his work with both TEE and angiogram. Would we code the 75898 in addition to 33340?

For thrombectomy/embolectomy of iliac stent, would I use 35875 or 34201?

I know that atherectomy bundles thrombectomy in the same vascular territory, and an example given is that the profunda femoral artery is a separate vascular territory than the common femoral, but does this make any of the three below-knee vessels (specifically anterior tibial) separate vascular territories than the superficial femoral or are they all the same because they all feed the foot?

A TEVAR extends into the arch; however, a stent (37236) was placed in the left subclavian keeping flow patent. Our description of 33880 says, "In 33880, the aneurysm extends beyond the origin of the subclavian artery and the stent-graft covers and occludes the left subclavian artery." I'm unsure if this counts as "covered" since blood flow is still patent. Should 33880 or 33881 be billed?

Can 37253 be additionally reported for IVUS of tibioperoneal trunk?

Procedures are stent of SFA and POPA, atherectomy/ang ATA

IVUS SFA, POPA, TBT

A 6 x 45 sheath was placed up and over a stiff wire into the R CFA and a cath was placed distally into the SFA were dx angiograms were performed which revealed total occlusion of the distal SFA and popliteal proximal PA with collateralization to the below the knee PA with one-vessel ATA runoff with a subtotal occlusion of the proximal ATA the interosseous and probe PTA filled distally with collateralization.

P IVUS of the right SFA and PA as well as TPT revealed a severe disease in the SFA multiple areas of 90% and greater and a total occlusion of the distal SFA and proximal PA with reconstitution below the knee PA with severe subtotal occlusion of the ATA.

I have an account where the physician has stented coronary arteries due to "ruptured plaque". However, the % of stenosis is less than 70% (60% is what is documented for left circumflex). The patient was documented as having an acute MI and the pain relieved after stent insertion.

Due to it not meeting the % of stenosis, can I code a DES insertion CPT for this procedure?

Middle adrenal artery (off of aorta) was selected with angiogram, and the medial and lateral limbs were selected with angiograms. Are these limbs coded as branches with 36246, 36248, 75774 x 2 on top of 75731?

How would I code a physician-modified fenestrated endovascular aneurysm repair done in an emergent situation?

Taking an off the shelf EVAR and creating his own fenestrated graft, then putting in Viabahn graft in the renals and SMA.

Would this be coded as an EVAR with stents or a FEVAR?

Provider performed a VATS right upper lobectomy and a therapeutic wedge resection of the right lower lobe for a contiguous lesion. Can we bill for both procedures performed on the same side but different lobes when the lesion is contiguous using CPT codes 32663 and 32666. If not, what CPT codes would you suggest?

Can you provide some guidance on whether or not we should be combining CT views into ONE CODE, same body part multiple hours apart.

The example below shows two CT Chest performed 8 hours apart, in this case should they both be combined regardless of the duration between the two. Or billed out separately, with each specific CPT done at that time.

CT Chest with contrast 71260 at 1:53 AM

CT Chest without contrast 71250 at 9:52 AM

A physician brought the patient to the cath lab for a right and left heart cath. Also the patient had a fluid challenge.

"....balloon-tipped Swan-Ganz catheter was advanced through the venous sheath into the pulmonary artery with serial measurements of hemodynamics and oximetry being performed. A fluid challenge was conducted with a 400mL bolus of normal saline and the catheter in the wedge position. "

Hemodynamics for the RHC listed (only one set)

Fluid Challenge (ACC Guidelines: Abnormal fluid challenge PWCP>18mm Hg after 400 mL fluid challenge)

Does this meet criteria for a 93464 Pharmacologic agent administration including assessing hemodynamic measurements? I didn't see a before, during or after but only the word "mean".

If a patient has a pacemaker/ICD implanted first, and in the same session/day has an AV node ablation without ever being taken off the table from the pacer/ICD procedure, is it appropriate to code re-programming 93286/7 for the AV node ablation portion of the procedure? We haven't been coding this as we know that 93286/7 is included in the pacemaker/ICD implantation. We have been following medaxiom, 93286/7 which states, "A patient has received an internal pacemaker/ICD generator and returns at a later date for surgery unrelated to the pacemaker." Because the AV Node ablation is done after the pacer/ICD is implanted, some think it is ok to code 93286/7 even if done in the same session/day. What would your guidance be? Thanks!

Patient is having a CABG with Impella 5.5 device placed with graft. For Impella with graft would this be 33990, 34716- graft to the suprasternal notch (LT/RT?) or because the chest is open when the VAD is implanted some of the providers believe it should be coded as 33979?

"An 8 mm graft was sewn to the ascending aorta using 4-0 polypropylene suture. The graft was exteriorized to through a skin tunnel above the suprasternal notch. An Impella 5.5 device was placed through this graft and then through the aortic valve."

The below documentation is what I usually find when my physician performs a heart cath and then catheterizes the innominate vein. She wants us to code either 75820-26 or 75827-26, but I don't feel this is diagnostic. In a meeting she stated that she's looking for collateral veins off of the innominate vein, but the reason is never documented in the report, nor is any other reason that might support that this was performed diagnostically, unless collateral veins are actually found. I feel comfortable coding 36011, but I don't feel comfortable assigning either of the two RS&I codes based on the below documentation. Thoughts?

"Left innominate vein angiography: With the tip of the Berman catheter positioned in the left innominate vein, angiography was performed. This demonstrates normal flow of contrast from the left innominate vein into the superior vena cava and right atrium."

PROCEDURE: 

1) Exploratory laparotomy

2). Resection of Superior mesenteric artery pseudoaneurysm.

The patient had an SMA pseudoaneurym. The surgeon states, "The SMA artery was then clamped. We opened the aneurysm. Upon opening of the aneurysm, significant brisk back bleeding was encountered to suggest adequate collateralization. All backbleeding branches were suture ligated. The PSA was unroofed, and specimen was sent to both pathology and micro for evaluation. The main inflow of the SMA PSA WAS LIGATED with 4-0 prolene in a running fashion. The SMA was unclamped and noted to be hemostatic."

Chart review reveals documentation that the patient is status post sma ligation. H& P shows planning for a ligation: "Overall, given how distal the SMA aneurysm is there is no reconstructable option and will require ligation." Surgeon confirms Ligation , bowel was run by Gen Surg for perfusion afterwards (did not participate in ligation)

I am inclined to use 37617, & let Gen Surg use 49000, but Auditors insist on 35121-62 for both. Can you help please?

How would you code the following scenario? 36466 is what's being suggest. I'm not so sure..

PROCEDURE SUMMARY: Percutaneous sclerotherapy of left vulvar varices using STS

Initial imaging

The patient was positioned supine. Initial imaging was performed using ultrasound.

Findings: Multiple prominent varices in the left vulva.

Needle/catheter placement

Local anesthesia was administered. The varices were accessed under imaging guidance.

Sclerotherapy

Sclerosant was injected into the collection.

- Sclerosant used: Sotradecol

- Additional sclerotherapy details: Foamed in approximate 12 cc air to 2 cc STS ratio.

- Sclerosant volume (mL): 3 cc of STS 3%

Additional narrative details: None.

Impression:

Impression: Image-guided percutaneous venous sclerotherapy

Thank you!

"Patient is being seen for right phrenic arteriogram and particle embolization. Artertiograms are done on the common hepatic, right hepatic, and left hepatic. The HI flow microcatheter was then placed in the left hepatic artery, and left hepatic arteriogram was obtained. The microcatheter was advanced into the medial segment left hepatic artery and arteriogram obtained from this location followed by CT/DSA imaging. Again after confirming no aberrant arteries, 3 mCi technetium 99 MAA was infused." 

For the catheter selections, are codes 36247, 36248 appropriate? Or should it be 36247, 36248 x 2 since it was also placed in the medial segment?

I am having a difficult time finding the cpt code for excision of left upper extremity subcutaneous cyst.

Left upper extremity prepped and draped. Over the palpable mass 3 cm incision was made and dissection into the subcutaneous tissues was done using Bovie electrocautery. We did not identify an abscess however we did identify a subcutaneous cystlike structure likely correlating to the ultrasound findings. The cyst was dissected free of the surrounding soft tissues using Metzenbaums. We did note a vein flowing into and out of the cyst which was clamped and suture-ligated. The cyst was removed and passed off the specimen

Which code is used for a CT-guided drain placement in a femoral bone abscess?

If you are in the left superior pulmonary vein and perform venoplasty of left superior pulmonary vein, left lingular vein, left inferior part of lingular vein, and intrasegmental part (anterior vein), can you code 37248 x 1 and 37249 x 3?

Our physician did a stent placement in the internal carotid with a shockwave lithotripsy. Would we use an unlisted code?

If a new patient is seen in an orthopedic office and the provider personally performs a fluoroscopy to assess an injury (no other procedure is performed this day and the imaging is saved/interpretation noted), could this be billed in addition to the E&M code? If it can be billed, which procedure code should be utilized, 76000 or 76496?

CPT 76000—fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time

CPT 76496—unlisted fluoroscopic procedure (eg, diagnostic, interventional)

Is there a CPT code for cerebral venous pressure during venography and venous catheter placement? Question was asked back in 2017, question 8841.

What exactly classifies as "complete" when doing a PVI ablation? If the LSPV, LIPV, RSPV, RIPV are all done, is that complete? Counts as 1 or is this 4? There is some disagreements in regards to what 'complete' really means. Pt had LSPV and LIPV ablated. Then the RSPV and RIPV were ablated. No more than 20W for 20sec was used along posterior wall.

Some of our coders are saying this is 1 ablation 93656. Others are saying that it is a total of 5 here. (not looking at MUE, just as a teaching example) 93656, 93657x4. OR is it 3? LSPV/LIPV RSPV/RIPV Posterior wall? My understanding is that this would be 93656, 93657. The PVs and then the posterior wall. I've looked through your archives trying to find an explanation that dumbs it down and have not found what we are looking for. If you can explain the PV ablations in layman, that would be good. We appreciate you very much.

I have a doc that does multiple embolizations in a single session in different arteries. The Mue for Medicare is 2 but he does anywhere from 5-10 different areas. Can I bill this many and appeal the denial with documentation?

Pt. presented for upgrade of dual pacemaker to BiVentricular. Laser extraction of existing RV lead, removal of dual generator, insertion of new RV lead, new multi pacing generator and insertion of new LV lead; existing RA lead re-utilized and connected to the new generator. Would this be removal lead from dual system 33235, insert/replace pacemaker ventricular 33207, and 33225? Would we report 33233 as well? Thanks in advance!

Hello,

I’m thinking the below procedure would be coded as 37799 but I’m hoping there is/are actual procedure code(s) I could assign instead.

Patient came into the OR w/ palmar arch injury w/intraluminal thrombosis. No inflow or proximal stumps of lacerated thumb vessels identified. Distal stump of the thumb ulnar digital artery was

identified dissection performed to obtain additional distal length. Artery was debrided back to normal healthy intima. The radial artery to the index finger was open w/ pulsatile flow. We elected to use the radial artery to the index finger as our inflow to revasc the left thumb. Dissection was performed to release the artery, it was clipped distally & cut & rotated to be utilized for micro anastomosis. Next, a 9-0 Nylon suture was used to perform the anastomosis in standard microsurgical fashion. The clamps were removed. Next arteriotomy over proximal radial aspect of the superficial palmar arch was performed and catheter was used to evacuate all clots and restoration of antegrade and retrograde pulsatile flow.

A cavotricuspid isthmus was visualized, which demonstrated a convoluted CTI line with ridges and valleys, including a large proximal ridge. A Decanav decapolar catheter was advanced to coronary sinus. A Vizigo long sheath was advanced into the heart which a ThermoCool STSF ablation catheter was advanced into the RA. The CTI line was interrogated with pacing,demonstrating breakthrough near the distal portion of the line in a pouch. Ablation at this location resulted in line of block. The CTI line was further interrogated, which demonstrated widely spaced double potentials. The line was reinforced for redundancy. After a suitable waiting period, widely spaced double potentials were confirmed along the full extent of the line. Additional bidirectional and differential pacing additionally demonstrated line of block.

I would bill this as 93653 and 93655?

61626 or 61624? Would this also be two separate locations or one surgical field?

PROCEDURE PERFORMED:

1. Diagnostic cerebral arteriogram with catheterization and injection of the right internal carotid artery, right external carotid artery, left internal carotid artery, and the left external carotid artery.

2. n-BCA embolization of traumatic left ECA trunk pseudoaneurysm, evaluated by control and final angiograms from the left external and common carotid arteries during the embolization to assess progress.

3. n-BCA embolization of traumatic left ascending pharyngeal artery pseudoaneurysm, evaluated by control and final angiograms from the left external and common carotid arteries during the embolization to assess progress.  These two pseudoaneurysms are arising from different arteries and represent two separate pathological locations.

93656 redo PVI vs. 93653, 93655, 93462, 93662.

"Patient in for redo PVI.....Dual transseptal puncture was performed under ICE guidance. At baseline all PV were isolated, there was some recovery along the mid posterior wall. Two linear ablation was performed from the mitral valve annulus to the RSPV and LSPV roof isolating the Bachman's bundle. The conduction time from surface p wave to LAA was 200 msec. An atypical atrial flutter was induced spontaneously with a CL of 340 msec. Activation map with Ensite EAM demonstrated that this to be an endo-epi Bachman re-entrant flutter from LAA to RSPV. RF along the LSPV roof/ LAA base then changed the CL to 470msec with a different activation from RSPV septum to LAA inferior base. RF there then terminated the flutter. Further RF was also performed isolating the posterior wall."

Our cardiologists bill code 99152 for conscious sedation for their inpatient and outpatient procedures. The physicians are questioning why code 99153 is not being billed when the sedation time is over 15 minutes. I read in a previous question from 2017 that the physicians cannot bill the 99153 code, only the facility may bill 99153. Is that still true? Or have there been any changes where the cardiology physicians can bill 99153?

Can you please tell me the appropriate codes to use for abdominal and renal angiography during left heart cath? 

"A French pigtail catheter was used for abdominal angiography. Two right renal arteries were identified with evidence of severe bifurcation stenosis in the superior renal artery. The inferior renal artery could not be visualized non-selectively. I placed an FR4 catheter in the inferior renal artery and injected dye, demonstrating an ostial stenosis on the order of 80% with pressure gradient of approximately 20 mmHg."

Would a contrast injection of a MACE catheter be coded with 49465 or 20501/76080? The patient is status post Mitrofanoff and Malone procedure.

During a CABG procedure the surgeon completes vein bypass to the first diagonal, artery bypass to the second diagonal, vein bypass to the RCA. The surgeons note there was an area of long soft plaque of the PDA (states significant finding) and completes a patch angioplasty. We know the bypass CPT codes, our question is can a patch angioplasty of the PDA be reported as well? What CPT would best capture this service?

Physician excised TWO old prosthetic grafts - for nothing. Not infected or thrombosed and no longer attached to any vessels.

"A long longitudinal incision was made in the mid upper arm directly over prosthetic grafts. The incision was deepened through the subcutaneous tissue with cautery. The grafts were identified. There were two old grafts present, which had been disincorporated from the underlying vessels."

That usually goes to 37799, but I'd rather code excision of foreign body, upper arm, deep, 24201. What do you think?

Patient had comprehensive EP study for AVRT and ablation to right lateral annulus aspect tricuspid valve. The doctors med report shows the patient's accessory pathway returned and patient will proceed with repeat ablations tomorrow. I am not sure if this is a focused EP study or a follow-up EP study because it was a planned procedure. During this study ablation was done to the slow pathway and RL/RPL accessory pathway. Isuprel was used and delta wave did not return, the patient was non-inducible for his AVNRT. Please confirm the correct codes 93653 or 93624-26, 93655, 93623.

The left vertebral comes off of the aortic arch. The provider angio’d the left subclavian separately, patient has severe subclavian artery narrowing that he wanted to quantify. Can we bill for the subclavian artery as well? If so, how would we code it?